NC Department of Health & Human Services (DHHS) In-Reach/Transition Manual

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Transitions to Community Living Initiative (TCLI)

In-Reach and Transition Manual

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TABLE OF CONTENTS Section Page

I. In-Reach Function 3 a. Priority Population 3

II. Administrative Components of In-Reach 4 a. Required Skills, Experience and Education 4 b. LME/MCO Oversight 5 c. Expectations of In-Reach Function 6 d. Materials 7

III. Step by Step Procedures for In-Reach 7 a. Adult Care Home: Priority 1, Priority 2, Priority 3 7 b. State Psychiatric Hospitals: Priority 4 11 c. In-Reach Services: Priority 5-DIVERSION 14 d. Other Administrative/Programmatic Guidelines 14 e. Documenting In-Reach Activities 15 f. Individual’s Rights and Reporting Concerns 16

IV. Reporting Complaints about LME/MCO In-Reach Activities 17

V. Transition Coordination Function 18

VI. Administrative Components of Transition 19 a. Required Skills, Experience and Education 19 b. LME/MCO Oversight 19

VII. Step by Step Procedures for Transition Planning 20 a. Procedures-Vital Documents 23 b. Procedures-Behavioral Health Linkage and Referral 24 c. Procedures-Other Health Needs 25 d. Procedures-Housing 26 e. Procedures-Financial Supports 28 f. Procedures-Community Resources 29 g. Procedures-Final Transition Meeting 30 h. Procedures-Follow Along (90 days post transition) 31

and Post Follow Along

VIII. Other Administrative/Programmatic Guidelines 31 a. Documenting Transition Activities 31 b. Transition Timeline and Overview 32

IX. Appendix 33

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I. IN-REACH FUNCTION In-Reach is an engagement, education and support effort designed to accurately and fully inform adults who have a serious mental illness (SMI) or a serious and persistent mental illness (SPMI) about community-based mental health services (including Individual Placement and Support- Supported employment (IPS-SE)) and supported housing options. This includes, but is not limited to, the availability of tenancy support services and rental assistance.

In-Reach is ongoing with the goal of educating individuals about all services that may be beneficial to him/her as well as community-based options:

The choice to transition to supported housing The choice to choose from an array of services and supports available to those living in

supported housing, including rental subsidy and tenancy supports The choice to remain in the adult care home (ACH) and the services that can be offered to

support the individual in that setting The choice to receive information about Medicaid, Special Assistance, and services under the

North Carolina State Plan for Medical Assistance or the state-funded service array for which the individual is eligible

The choice to consider employment through Supported Employment (SE) or the Division of Vocational Rehabilitation (DVR)

The choice to request and receive, information on community activities and resources that match their interests and needs (social, recreational, educational, faith based, health and wellness, etc.) and the choice about which they want to participate in and/or use.

The choice to request and receive from the In-Reach staff, opportunities to actively engage with other individuals who are living, working and receiving services in the community

In-Reach staff should utilize community inclusion and integration activities to actively engage individuals with peers in the community. This should occur as early as possible to ensure individuals can make an informed choice about where they want to live, work and learn.

Local Management Entity-Managed Care Organizations (LME/MCOs) will prioritize In-Reach to ACHs determined to be an Institution for Mental Disease (IMD).

A. Priority Population The priority population for In-Reach includes the following categories per page five the Settlement Agreement:

1. Individuals with SMI who reside in ACHs determined by the state to be an IMD 2. Individuals with SPMI who are residing in ACHs licensed for at least 50 beds and in which 25

percent or more of the resident population have a mental illness 3. Individuals with SPMI who are residing in ACHs licensed for between 20 and 49 beds and in

which 40 percent or more of the resident population have a mental illness 4. Individuals with SPMI who are or will be discharged from a State Psychiatric Hospital (SPH)

and who are homeless or have unstable housing

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5. Individuals diverted from entry into ACHs pursuant to the pre-admission screening and diversion provisions established by the State

**Note: Any individual residing in an IMD as of August 23, 2012 is considered first priority regardless of where they are currently living. This may result in providing In-Reach to an area not previously defined in Settlement Agreement, such as group homes and shelters.

Each LME/MCO receives information on those who are identified as potentially eligible for one of the Priority Populations in the following ways:

• Priority 1, 2 and 3: a spreadsheet is downloaded to a secure FTP site at each LME/MCO. “The annual In-Reach list is based on claims, which means that it can both include people who aren’t eligible, as well as, exclude individuals who are eligible. “If an ACH is on the annual In-Reach list, and an individual living there is found to have SMI/SPMI, then that individual is eligible for In-Reach.

• Priority 4: list of individuals in each SPH is downloaded to a secure FTP site for the home LME/MCO

• Priority 5: individuals who were identified through the diversion process, who were not diverted from an ACH are automatically eligible for on-going In-Reach services

These individuals also are considered a member of the Special Healthcare Population being served by the LME/MCO Care Coordination and are expected to be followed by care coordination, after the 90-day transition period has ended.

II. ADMINISTRATIVE COMPONENTS OF IN-REACH:

A. Required Skills, Experience and Education In-Reach staff must be a North Carolina Certified Peer Support Specialist1 (CPSS). Eligibility requirements for a CPSS are; 18 years or older; have lived experiences in recovery from a significant mental health or substance use disorder; have been in recovery for at least one year; and have a minimum of a high school diploma/GED. Requires years of experience working with the Mental Health (MH)and Substance Use (SU) population (CPSS must be certified within six months of hire). CPSS are individuals who provide support to others who can benefit from their lived experiences.

If an LME/MCO has limited availability of a qualified CPSS in their catchment area, efforts to build capacity, train, and recruit CPSSs must be documented and continuous. The peer support specialist position may be contracted out, but the LME/MCO remains responsible for ensuring required activities are completed.

It is the responsibility of the LME/MCO to ensure In-Reach staff are knowledgeable about all community-based resources and services, such as: Medicaid and Special Assistance benefits,

1 http://pss.unc.edu/index.php

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available clinical services, community supports, supported housing; SE; and other means of community participation. If an individual and/or guardian has questions about the Olmstead decision or Americans with Disabilities Act (ADA), the In-Reach Specialist should refer them to the appropriate LME/MCO staff.

Since a large portion of the Transitions to Community Living Initiative (TCLI) population have physical health concerns, In-Reach staff should be knowledgeable about and/or know how to link individuals to appropriate medical services.

In-Reach staff receive training in the following skill set, prior to working independently with individuals:

• Assertive Engagement • Motivational Interviewing2 • Active Listening Skills • and other relevant methods of Engagement

All In-Reach Specialists take Intentional Peer Support training – equipping them with a solid foundation on what is expected as a Peer Support Specialist.

Motivational interviewing is an introductory and intermediate training facilitated by SA trainer certified by the Motivational Interviewing Network of Trainers (MINT). This gives the In-Reach Specialists great tools to engage with individuals in the early stages of change around moving.

Additional training suggestions for In-Reach Specialists, include but are not limited to: 1. Stage of Change Treatment - helps identify the skills and tools to use with individuals based

on their presenting stage of change. 2. Brief Strengths Based Case Management for Substance Abuse- although the primary focus

has been on adults with substance use and adults with HIV, the focus is linking and connecting with care. The five guiding principles are:

• Encourage identification and use of strengths, abilities and assets. • Recognize and support client control over goal-setting and the search for needed

resources. • Establish an effective working relationship. • View the community as a resource and identify informal sources of support. • Conduct case management as an active, community-based activity.

B. LME/MCO Oversight LME/MCOs are the entity responsible for coordinating and overseeing the completion of In-Reach activities, including documenting in accordance with the Department of Health and Human Services (DHHS) approved guidelines.

2 http://www.motivationalinterviewing.org/

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Each LME/MCO validates the Medicaid county of origin for each individual referred for activities under the Settlement Agreement. The LME/MCO assumes primary responsibility for In-Reach and Transition for individuals whose Medicaid originates in counties in their catchment area (home LME/MCO). This does not preclude LME/MCOs collaborating to meet the needs of individuals who reside in another LME/MCO catchment area (host LME/MCO) or those who wish to transfer to another area.

Each LME/MCO must create procedures documenting the method by which initial and ongoing In-Reach activities will be completed and documented. These procedures must be consistent with the requirements and directives provided by the DHHS. Procedures related to In-Reach should be made available upon request.

DHHS will sponsor ongoing training regarding In-Reach activities. Staff from the LME/MCO are required to attend the training. Additional training in engagement skills and supports may be necessary and be guided by the LME/MCO staff needs assessment.

C. Expectations of In-Reach FunctionGood communication skills are key to setting the tone for successful In-Reach activities. Examples include:

• Building Trust- Prior to the meeting to gather information, attempts should be made tomake the individual feel at ease. This can be accomplished by talking to the individual about:o everyday activities, social conversations, looking through family pictures, etc.;o natural supports who would like to be a part of the continuum of support; ando their strengths and what they want to do.

• Establishing Rapport - Active listening skills can lead to good rapport and engagement. Thisincludes paraphrasing what has been heard, gently encouraging the individual to continuetalking and validating the individual’s feelings.

• Communication - Person-centered dialogue is central to learning more about theindividual’s values, strengths, preferences and concerns. It is an effective method to gatheraccurate information about the individual and the supports that may be needed for asuccessful transition to the community. Person-centered interaction supports informedchoice and decision-support processes, which may include:o Taking the individual into the community to see what supported housing is like

(visiting/talking to individuals that live in the community, observing individuals on thejob as they work, visiting places in the community they want to live, etc.);

o Listening to the individual express his/her preferences, values, service needs andcircumstances;

o Engaging in conversation for a mutual exchange of information and possible optionsthat are tailored around the stated needs and preferences;

o Providing support that leads the individual to make informed choices about long-termservices and supports;

o Connecting the individual, when it is his/her choice, to public/private services and/orinformal supports, and

o Following-up with the individual with the ultimate goal to support the individual to livein his/her community of choice.

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D. Materials Each LME/MCO must keep up-to-date materials for dissemination to interested individuals and have a section of the agency website dedicated to TCLI. This includes, at minimum, a brief description of TCLI, the process overview and local contact information.

III. STEP BY STEP PROCEDURES FOR IN-REACH:

A. Adult Care Home: Priority 1, Priority 2, Priority 3 In-Reach services will follow an individual in the Department of Justice (DOJ) Special Healthcare population throughout their involvement in the TCLI, whether the person transitions into supported housing or remains in an ACH.

In-Reach will include: providing information about the benefits of supported housing, facilitating visits in such settings, and offering opportunities to meet with other individuals with disabilities who are living, working and receiving services in integrated settings, with their families and with community providers.

The following process will be followed for all individuals identified by DHHS as Priority 1, Priority 2, or Priority 3.

1. DHHS downloads spreadsheets to a secure FTP site at each LME/MCO, with information on individuals who are residing in ACHs who appear to meet the eligibility requirements for the DOJ Settlement Agreement.

2. The LME/MCO TCLI staff are responsible for reviewing the individuals listed and validate their diagnosis (SMI, SPMI), county (home county based on Medicaid) and note anything that could disqualify an individual (primary diagnosis of Dementia, Intellectual Developmental Disability (I/DD), Traumatic Brain Injury (TBI), or medical fragility that necessitates a person being in a 24-hour care facility).

3. DHHS will be notified if the LME/MCO staff identify that the individual is not eligible for consideration.

4. The LME/MCO will decide which ACH(s) to select to begin, or continue, the In-Reach process through review of eligible individuals, location of ACH, priority population and other criteria that may be identified.

5. Once the LME/MCO identifies the facility, communication will occur with the facilities listed, as well as consumers/guardians/legal guardians as follows: 1) A letter will be sent, following the DHHS approved format, to the owners of facilities

selected based on review of the prioritization of recipients. All letters will be sent by certified/tracked mail and time-stamped fax confirmation.

The Letter to ACH from the LME/MCO is available at: https://files.nc.gov/ncdhhs/documents/files/attachment-d.pdf?rHsRkPuBJ1BKlEz2LDwFNuz_jV6mOZeP

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2) LME/MCO In-Reach staff will contact the owner/administrator via telephone after confirmation that they have received the letter to arrange a time to meet (preferably face-to-face) or talk by phone at the convenience of the facility.

6. The following will occur during the call/face-to-face meeting: 1) Discuss the letter; 2) Educate the facility owner/administrator about the In-Reach process, helping them

understand the comprehensiveness of the process that fully informs individuals on their options for living arrangements (remain in ACH, moving into supported housing, exploring other residential options) and the services/supports that may be available to support the individuals wherever they choose to live;

3) Share and review forms used in the In-Reach process, which include The In-Reach/Transition to Community Living Tool (Revision November 2017) and Guidance documents;

The In-Reach TCL Tool is available at: https://files.nc.gov/ncdhhs/documents/files/Attachment%20B%20-In-Reach-TCL%20Tool_RevNov2017.pdf?rEoRfTEgxA2g6UB.eOf8MyXZCdC5ybfT

The In-Reach TCL Tool Guidance Document is available at: https://files.nc.gov/ncdhhs/documents/files/In-ReachTCLTool_Guidance%20Document.RevNov2017.pdf?elpDM5oAu2QBnTviYYZil5g48OlgICoa

The In-Reach TCL Tool Conversational Guidance Document is available at: https://files.nc.gov/ncdhhs/documents/files/In-ReachTCLTool_Conversational%20Guidance%20Document_RevNov2017.pdf?cT.upUc55Kq_m5hV.0A42Oel7laXrZue

4) Answer questions about In-Reach activities; 5) Advise the owner/administrator that the names of individuals already identified as

potentially eligible will be shared once individuals have been notified; 6) Inform them that for individuals who have a legal guardian, contact will be made with

that person prior to contacting the individual; 7) Advise the facility owner/administrator that they can ask that a resident individual be

reviewed to determine eligibility for TCLI; and 8) Solicit input from the facility owner/administrator on scheduling visits for individuals

and/or guardians (point of contact, best days and times, as not to interfere with the programs and activities in the ACH or other activities/appointments of individuals, times to avoid, etc.).

7. In-Reach staff will send a letter to individuals identified in the ACH (as reflected by the DHHS spreadsheet) or guardian, following the DHHS approved format via trackable mail. The letter will detail the In-Reach process and offer times for face-to-face meetings. It will also include contact information for the In-Reach staff to ensure meetings are scheduled during times that are convenient to the individual, guardian and facility.

The Letter to Individual from the LME/MCO is available at: https://files.nc.gov/ncdhhs/documents/files/attachment-e.pdf?rycSPidmf7TpdoJWxATuY5.8rpq3JRZS

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The Letter to Guardian from the LME/MCO is available at: https://files.nc.gov/ncdhhs/documents/files/attachment-f.pdf?nF7i1Kyx2zYh4exegaNVBM311S7C_oRp

8. Once confirmed that the letter(s) have been received, the In-Reach Specialist will contact individuals and/or their guardians as applicable to confirm appointments. They will also be informed that the individual may invite others to the face-to-face meeting if they choose. Written consent will be obtained from the individual or legal guardian before allowing others to participate.

9. In-Reach staff will make direct contact with the administrator of the facility and/or their designee to confirm the scheduled time for In-Reach activities. Meetings will usually occur at the facility, but can be held in any location requested by the individual.

10. Prior to the initial face-to-face meeting, In-Reach staff should gather information to prepare for the visit using the In-Reach Guidance Checklist.

The In-Reach Guidance Checklist is available at: https://files.nc.gov/ncdhhs/documents/files/attachment-a.pdf?dOtuJilRTTEpECNGuUww2S4IpDNIQn7s

11. During the initial visit, the In-Reach Specialist will establish rapport with the individual, provide basic information about TCLI and respond to any questions. At the end of the initial visit, the individual should be provided with contact information to reach the In-Reach Specialist.

12. To assist in determining their interest in Supported Housing, the In-Reach staff should utilize the script “Did You Know You Can Choose Where You Live?”

The Did You Know You Can Choose Where You Live? (ACH) is available at: https://files.nc.gov/ncdhhs/documents/files/attachment-b%20%28RevSept2017%29.pdf?TAFCTCMAE1pk8pILGTAp3JtBaapcnEQ0

13. The In-Reach Specialist may introduce the DHHS In-Reach/Transition to Community Living Tool (Revision November 2017) to gather information and guide the conversation during the initial visit. The tool is a resource for the individual/guardian and others, in identifying needs; preferences; interests; what is important to; and important for the individual. The goal is to gather as much information as possible throughout the process.

14. In exploring interests and needs of the individual, the LME/MCO In-Reach Specialist should ask about: a. Past living situations (independent living, family, hospital, group home, ACH, SNF,

boarding homes, friends, shelters etc.) 1) Where the individual lived prior to the ACH? 2) Why the individual/guardian chose the current setting? 3) Whether anyone helped the individual learn about other options? 4) What did the individual do with their time? What did a typical day/week look like? 5) What roles did the individual have? (mother, father, friend, co-worker, student,

employee) b. Current living situation to include supports:

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1) Medical services 2) Personal Assistance 3) Any type of special therapies (Occupational Therapy, Physical Therapy) 4) Behavioral health services to include medication management 5) Employment 6) Community participation activities and transportation (How they spend their time?) 7) Do they have contact with outside friends or family?

15. The In-Reach Specialist will meet with the individual as many times as requested to help them explore options; respond to questions and provide additional resources as requested. Release of information (ROI) forms to receive additional information may be explained and signatures received.

16. The In-Reach Specialist will inform the individual of what life on an everyday basis might be like as well as educate the individual and/or legal guardian on services and supports that are available to assist the individual to transition to a community setting, to include but not be limited to:

a. A description of the individual’s ideal living situation b. A description of what the individual would like to do with their time c. The individual’s strengths d. Supported employment opportunities e. Housing and geographic location preferences f. Concerns or fears the individual may have about living in supported housing g. Local supported living options h. Costs i. Consumer-directed options j. Transportation

** Note: many of these topics are also discussed in the context of supporting someone who chooses not to move.

If individual is not interested in supported housing

17. If the individual indicates that he/she is not interested in supported housing, this will be

documented in Transitions to Community Living Database (TCLD). The In-Reach Specialist will explore and address all concerns of any individual who declines the opportunity for supported housing or is unsure about moving.

18. For those with a legal guardian, any decisions about supported housing or services and supports should include the individual’s preferences to the extent possible. If this is not occurring, the LME/MCO staff will address through client rights protocols.

19. The individual and/or guardian, as appropriate, and facility staff will be informed that follow-up In-Reach (face-to-face, letter or telephone call) will occur at a minimum of every 90 days. The In-Reach Specialist will confirm that the individual, guardian and facility have contact information for the In-Reach staff in case they have questions or desire a visit before 90-days.

20. Throughout the In-Reach process, In-Reach staff will continue to educate the individual/ guardian/ facility on resources in the community (including supported housing, supported employment), benefits and financial aspects of living in the community, Medicaid and

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Special Assistance funds, as well as services covered under the North Carolina State Plan for Medical Assistance, Medicaid 1915 (b)(c) waiver and the state-funded service array.

*During In-Reach, a great opportunity to educate the individual and/or guardian on the resources in the community is to take the individual into the community to see what supported housing is like. For example, visiting/talking to individuals that live in the community; observing individuals as they interact in the community; and/or visiting places in the community they say they may want to live, work, or learn.

If individual only expresses interest in services

21. If the individual expresses an interest in receiving behavioral health services or supported employment, the LME/MCO should implement care coordination activities and link the individual to services and assessments indicated.

22. If the individual indicates prior to discharge that he/she is only discharging to another setting (i.e., MH group home, move-in with family or friends, etc.) for temporary housing, In-Reach will continue to occur at a minimum of every 90 days.

If an individual expresses interest in supported housing

23. If the individual indicates that he/she is interested in supported housing, the process for requesting a Housing Slot will be followed. If a person agrees to transition into the community, a housing slot should be obtained within 10 calendar days.

B. State Psychiatric Hospitals: Priority 4 1. Priority 4 individuals are those with SPMI who are or will be discharged from a SPH and who

are homeless or have unstable housing. 2. SPH staff will upload a list of Priority 4 individuals who are potentially eligible for In-Reach to

the secure FTP site for the home LME/MCO monthly. 3. LME/MCO staff will download their SPH In-Reach lists from the FTP site and review data

provided in addition to information within the LME/MCO system on a monthly basis. 4. SPH staff will consult with the individuals and/or legal guardians and provide an overview of

the TCLI Program. They will also inform the LME/MCO staff of interests, concerns or resistance. The SPH staff will provide an overview of TCLI to the people they think are eligible. This work is ongoing, as people are frequently entering and leaving the state hospitals.

5. LME/MCO staff coordinates the In-Reach process with the designated hospital Social Worker, including validating contact information for legal guardians as applicable.

6. LME/MCO In-Reach staff will gather information to prepare for the initial visit using the In-Reach Guidance Checklist at: https://files.nc.gov/ncdhhs/documents/files/attachment-a.pdf?dOtuJilRTTEpECNGuUww2S4IpDNIQn7s

7. In-Reach starts when LME/MCO In-Reach staff or SPH Social Worker staff make the first documented contact with the individual or guardian. Initial contact may be in person, by phone or letter to the individual or guardian (if they have a guardian) and should be made

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prior to the individual leaving the hospital. A face-to-face visit is the preferred method of contact.

8. Subsequent meetings will be coordinated with the SPH Social Worker (if the individual is still in the SPH) and will include the individual, legal guardian (if applicable) and others that the individual may choose to have involved.

9. The In-Reach Specialist will establish rapport with the individual and provide basic information to them about TCLI and respond to any questions. The script “Did You Know You Can Choose Where You Live?” may be used to inform the individual about the opportunity to choose where he/she can live upon discharge.

The Did You Know You Can Choose Where You Live? (SPH) is available at: https://files.nc.gov/ncdhhs/documents/files/attachment-c%20%28RevSept2017%29.pdf?fHfzV7Z1lz5ZzoTjUU1QdKiaAsOXbH3G

10. The In-Reach Specialist will utilize the In-Reach-Transition to Community Living Tool (Revision November 2017) and guidance documents to assist in the process of obtaining information.

11. In exploring interests and needs of the individual, the LME/MCO In-Reach Specialist should ask about:

a. Where the individual lived prior to State Psychiatric Hospitalization? b. Past living situations (independent living, family, hospital, group home, ACH, Skilled

Nursing Facility (SNF), boarding homes, friends, shelters etc.) c. What did the individual do with their time? What did a typical day/week look like? d. What life roles did the individual have? (mother, father, friend, co-worker, student,

employer) e. What the individual would like to do with their time? f. What are the services and activities the individual participates in at the hospital, to

include any type of specialized therapies to address physical problems (OT, PT) or co-occurring diagnoses (such as Substance Abuse Services)?

12. The In-Reach Specialist will talk with the individual as many times as requested by the individual, or as needed, to help explore their options, respond to questions and provide additional resources. Release of information forms to receive additional information may be explained and signatures received; for example, if additional medical records are needed to facilitate a referral to a therapy like OT, the Specialist will obtain the records to facilitate the referral after receiving signed consent.

13. The In-Reach Specialist will educate the individual/legal guardian on services and supports that are available to help the individual become involved in their community. This includes, but is not limited to:

a. A description of the individual’s ideal living situation b. A description of what the individual would like to do with their time c. The individual’s strengths d. SE opportunities e. Housing and geographic location preferences f. Concerns or fears the individual may have about living in supported housing g. Local supported living options h. Costs

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i. Consumer-directed options j. Transportation

If the individual states they are not interested in Supported Housing

14. If the individual indicates that he/she is not interested in supported housing, this will be documented. The In-Reach Specialist will explore and address all concerns of any individual who declines the opportunity for supported housing or is unsure about moving.

15. For those with a legal guardian, any decisions about supported housing or services and supports should include the individual’s preferences to the extent possible. If this does not occur, LME/MCO staff will address through client rights protocols.

16. The individual/ guardian, as appropriate, and SPH staff will be informed that follow-up In-Reach will occur at a minimum of every 90 days, whether the individual is still in the SPH or is discharged to another setting, such as an ACH.

17. If the individual continues placement in the SPH, the LME/MCO hospital liaison will continue to network with the SPH Social Worker and other staff, and will participate in ongoing treatment team meetings to include development of the Continuing Care Plan at discharge.

18. The In-Reach Specialist will confirm that the individual, guardian and facility have contact information for the In-Reach staff in case they have questions or desire a visit before 90-days.

19. Throughout the In-Reach process, staff will continue to educate the individual/ guardian/ facility on resources in the community (including supported housing, supported employment), benefits and financial aspects of living in the community, Medicaid and Special Assistance funds as well as services covered under the North Carolina State Plan for Medical Assistance, Medicaid 1915 (b)(c) waiver and the state-funded service array.

20. When the individual is discharged, the SPH Social Worker will communicate discharge placement and services to the In-Reach Specialist directly or through the LME/MCO Hospital Liaison. If the individual indicates, living in a .5600 licensed group home or their own place, is a permanent housing plan, In-Reach does not continue after discharge.

If an individual expresses interest in only services

21. If the individual expresses an interest in receiving behavioral health services or SE and is not already linked to either, the Hospital Liaison and Social worker should coordinate with the LME/MCO to ensure services are available upon discharge.

22. If the individual indicates prior to discharge that he/she is only discharging to another setting (i.e., MH group home, moving in with family or friends, etc.) for temporary housing purposes, In-Reach will continue to occur at a minimum of every 90 days.

If an individual states interest in Supported Housing

23. If the individual indicates that he/she is interested in supported housing, a Housing Slot will be requested.

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C. In-Reach Services: Priority 5- DIVERSION 1. Individuals diverted from placement in an ACH receive Options Counseling to educate them

about services and supports, including consideration for supported housing. 2. Individuals not diverted from ACH placement are automatically referred for In-Reach

services. 3. The In-Reach Specialist will contact individuals and/or their guardians within 90 days of

admission into the ACH to educate them about TCLI and the In-Reach process. 4. The In-Reach Specialist will follow the procedures for step-by-step procedures for In-Reach:

ACH: Priority 1, Priority 2, Priority 3 (above)

D. Other Administrative/Programmatic Guidelines

In Reach tracking for 90-day visits begin (the date LME/MCO staff enter a visit into TCLD) based on the following activities:

• ACH - In-Reach starts when the LME/MCO sends the ACH letter or LME/MCO make a contact with the individual or the guardian (if they have a guardian.)

• SPHs- In-Reach starts when the individual enters the hospital or when the first documented contact with the individual or guardian is made. Initial contact may be in person, by phone or letter to guardian (if they have a guardian) and should be made prior to the individual leaving the hospital. A face to face visit with the individual is the preferred method of contact.

For individuals on the In-Reach list (who are potentially eligible): if a letter is sent and later it is determined the person is not eligible (could be primary diagnosis of Dementia or no SMI/SPMI), they should not be entered into TCLD.

Once it is determined an individual meets the minimum criteria for the settlement, their information should be entered into TCLD. Once an In-Reach visit has been recorded in TCLD, the number of days since the last visit will be highlighted. Regardless of the method of contact, documentation is required in TCLD.

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LME/MCOs may implement the following tier system after In-Reach has begun and the first face-to-face contact:

Tier 1 Tier 2 Tier 3

Contact by phone or mail at least once every 90 days

Face-to-face contact at least once every other quarter. Mail or phone contact at least once during alternate quarters.

Face-to-face contact at least once every 90 days

Individual or Guardian has refused In-Reach

Individuals who are interested in services but have stated they are not interested in Supported Housing

Individuals who did not meet criteria for Level 1 or Level 2

Individual has been adjudicated incompetent and / or the guardian refuses to participate in discussion

When the interest list for housing slots exceeds twice the number of housing slots required to be filled in the current and subsequent fiscal year, DHHS may temporarily suspend In-Reach efforts.

E. Documenting In-Reach Activities Staff completing In-Reach and transition activities for LME/MCO must utilize the In-Reach/Transition to Community Living Tool (Revision November 2017) and any updated versions approved by DHHS. This document outlines key elements to support the In-Reach and transition process of the individual.

The LME/MCO shall document all In-Reach activities in accordance with DHHS guidelines that include data entry into the web-based system in effect at a point in time (currently TCLD). Data entry must occur in a timely manner to ensure system data reflects real-time activities with individuals. An on-line training module will be developed for LME/MCOs use, to allow timely access to training for new employees as well as refresher training for existing staff. Once completed, it will be available on the state TCLI WEB PAGE3. The current TCLD USER GUIDE4 is available for use.

The TCLD User Guide is available at: https://files.nc.gov/ncdhhs/documents/files/TCLD%20UserGuide.pdf?pBIm6s8ZUiPwYKNgq_Swdgkm9PxP3LJA

3 http://www.ncdhhs.gov/mhddsas/providers/dojsettlement/index.htm 4 https://www.socialserve.com/waitlist/Help.html?ch=NC&waitlist_id=11&back_ref=waitlist%3B11

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The LME/MCO shall also document direct activities with persons being served through established procedures within the respective LME/MCO that could include case notes.

In accordance with the DOJ Settlement, the LME/MCO must demonstrate compliance with and reporting of individual outcomes from In-Reach services to include (a) lack of response to written communication from the LME/MCO by individual or guardian; (b) refusal of an individual to meet with LME/MCO staff; and (c) refusal by a guardian for the individual to participate in the In-Reach process. All LME/MCO documentation shall be made available to the state upon request.

F. Individual’s Rights and Reporting Concerns The rights of individuals living in adult care homes are protected by state law. In accordance with law, the North Carolina’s Adult Care Home Bill of Rights outlines the rights of individuals residing in an ACH to include an individual’s right to associate and communicate privately and without restriction with people and groups of his or her choice. The right for them to participate in In-Reach services is covered here.

The Long-Term Care Ombudsmen serve as advocates for individuals living in ACHs throughout North Carolina. In addition, NC DHHS Division of Health Service Regulation (DHSR) monitors complaints regarding ACHs.

In the event an LME/MCO In-Reach staff is denied access to an ACH or to the individual for the purposes of completing In-Reach activities, LME/MCO staff will contact the regional Long-Term Care Ombudsman and the DHSR Complaint Intake Unit.

• The name and contact information for the regional Long-Term Care Ombudsman can be found at https://www.ncdhhs.gov/assistance/adult-services/long-term-care-ombudsman.

• The DHSR Complaint Intake Unit can be reached at 800-624-3004 or 919-855-4500. Additional information is available at: http://www.ncdhhs.gov/dhsr/ciu/complaintintake.html#contactinfo

If an LME/MCO has concerns regarding the care and services provided to an individual living at an ACH, the LME/MCO will file a complaint with the DHSR Complaint Intake Unit. The LME/MCO is should also discuss any concerns with the facility.

The instructions for Filing an Adult Care Home/Family Care Home complaint is available at: https://files.nc.gov/ncdhhs/documents/files/Filing%20an%20ACH%20Complaint%20Handout%20%28002%29.pdf?NNbSaPXAJGpFdcdASAxNFG9B0LGJrXIn

Article 6 of North Carolina General Statutes Chapter 108A, the “Duty to report; content to report; immunity” requires that: any person having reasonable cause to believe that a disabled adult needs protective services shall report such information. When you suspect mistreatment

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of an older adult or an adult with a disability, NC law requires you to contact Adult Protective Services (APS) at the Department of Social Services (DSS) in the county where the adult is living. Contact information for County DSS offices can be found at https://www.ncdhhs.gov/document/dss-county-directory

Individuals living in state-operated facilities are afforded all state and federal civil rights, including rights under: Article 3 of North Carolina General Statutes Chapter 122C, the Individuals with Disabilities Education Act (IDEA), The ADA, The Rehabilitation Act, the Civil Rights of Institutionalized Persons Act, and Title VI of the Civil Rights Act. Health Insurance Portability and Accountability Act (HIPAA) confidentiality protections also apply.

Consumer Advocates are in state-operated healthcare facilities and are available to individuals and their families, 24 hours a day, 7 days a week. Anyone receiving services in a state-operated facility has a right to express a concern or grievance without fear of retribution. Concerns or grievances can also be brought forward by a guardian or anyone authorized to speak on behalf of the individual receiving services.

Consumer Advocates also conduct timely investigations when there are reports or suspicions of rights violations, such as abuse, neglect or exploitation. In the event the LME/MCO has concerns regarding the care and services provided to an individual in a state-operated facility, the LME/MCO may file a complaint with the Consumer Advocate for that facility. A link to find the Advocate for each facility can be found at https://www.ncdhhs.gov/divisions/dsohf/facilities

Each facility has a Human Rights Committee appointed by the Secretary of DHHS. These committees also work to protect the rights of the people being served by the facility. The facility advocates support the mission of these Human Rights Committees by providing information regarding many aspects of the facilities’ programs for the committee to review. The Consumer Advocates are also available to follow-up on any matters of concern to the Human Rights Committees.

Each state is required by the federal government to be part of the federal Protection and Advocacy (P&A) system. Disability Rights North Carolina (DRNC)5 is a private non-profit organization that was designated by the Governor in 2007 as the P&A for North Carolina. DRNC can be contacted at 877-235-4210 or info@disabilityrightsnc.org

IV. Reporting Complaints about LME/MCO In-Reach Activities Each LME/MCO has a customer service department. All concerns or complaints about activities related to LME/MCO In-Reach efforts should be shared with the customer service department. In addition, concerns or complaints can be made to the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) Customer Service and Community Rights Team at 800-662-7030. LME/MCO In-Reach staff should provide individuals and facility administrators contact information

5 http://disabilityrightsnc.org/

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for the customer service department along with information on how to share any concerns or complaints related to LME/MCO In-Reach efforts.

V. Transition Coordination Function: Transition, by definition, is a process of changing, movement, development, or evolution from one state to another. The function of transition in TCLI is to assist individuals identified through the In-Reach or diversion process who voiced a desire to explore other possible community-based supported-living opportunities.

The primary purpose of transition coordination is to support a person transitioning from facility services in securing appropriate community-based housing and clinical services. This includes the LME/MCO assigning a Transition Coordinator who assumes primary responsibility for coordinating and managing the transition process. The goal is that the individual transitions into supported housing, with all domains addressed and all essential services and supports are in place, within 90 days from the initial transition planning meeting.

During this process, the Transition Coordinator:

• Maintains a commitment to person-centered transition practices congruent with the philosophy of recovery.

• Ensures transition planning is based on the principle that with sufficient services and supports, people with SMI or SPMI can live in an integrated setting.

• Models respectful, positive, “can do” attitude throughout the process. • Focuses on the collaboration of all partners and facilitation of services and resources. • Facilitates a comprehensive planning process to give individuals with disabilities the opportunity

to live in housing of their choice, with an array of services and supports that help them keep their housing, such as tenancy supports, conflict resolution and crisis response.

• Sees the person and their “family/friend/community network of supports” as central to the transition process

• Assists individuals in receiving support to become fully participating members of the community, including assistance with socialization and gainful employment.

Core responsibilities include, but are not limited to:

• Leading the transition process • Collaboration and facilitation • Transition planning • The transition • Follow along • Reporting requirements

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VI. Administrative Components of Transition:

A. Required Skills, Experience and Education Staff functioning as a Transition Coordinator should be employed by the LME/MCO. The individual in this role must meet minimum qualifications of a Qualified Professional (QP) in accordance with APSM 30-1:10A NCAC 27.G (19): Staff Qualifications. The Transition Coordinator must have a good understanding of person-centered thinking and planning and developing a transition planning team for the individual transitioning to supported housing. Knowledge of and experience with the following is critical:

• Housing • Behavioral Health resources (including linkage and referral) • Other health and wellness needs • Financial supports • Employment and vocational resources and supports • Community resources (faith-based, recreational and leisure, social, advocacy, support

groups, volunteer opportunities) • Benefits • Adaptive equipment needs • Crisis planning • Person-specific risk mitigation strategies • Cultural and linguistic needs of the individual

Included in knowledge and experience with the key domains, is the ability to identify resources/persons applicable to each individual and incorporating them into the Transition Team.

B. LME/MCO Oversight LME/MCOs have been identified by DHHS as the entity responsible for coordinating and overseeing the completion of the transition activities. LME/MCOs are responsible for documenting the completion of transition activities for applicable individuals whom Medicaid originates in a county for which the LME/MCO is responsible and for non- Medicaid individuals who reside in the LME/MCO catchment area. Transition coordination must be completed by LME/MCO staff knowledgeable about community services and supports, including supported housing. DHHS and NC Housing and Finance Agency (NCHFA) created and fund the Targeted Unit Transition Program (TUTP) which increases opportunities for individuals identified as needing housing through TCLI. Individuals waiting for a full transition to permanent supported housing and are in immediate need of interim housing should be evaluated for eligibility. LME/MCOs shall collaborate to achieve efficiencies for individuals whose Medicaid originates in a county covered by one LME/MCO but who resides in another LME/MCO’s catchment area.

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On December 10, 2015, Joint Communication Bulletin#172-New Procedures for In-Reach and Transitions Across Different LME/MCOs was released to clarify expectations related to the delivery of Behavioral Health services and supports. The bulletin outlined procedures to be in place on or before January 4, 2016. The desk reference below is meant to provide a framework on how LME/MCOs will collaborate to ensure an individual’s needs are met in various situations: The In-Reach and Transitioning Individuals between LME/MCOs is available at: https://files.nc.gov/ncdhhs/documents/files/TCLI-In-Reach-and-Transitioning-Individuals-between-LME-MCOs-Final-12-9-15_0.pdf?ffO60XeUFTkVBiK41uYWIkAqzdbs9WTR

Each LME/MCO is expected to create procedures documenting the method by which transition activities will be completed and documented. The procedures developed by the LME/MCO must be consistent with the requirements and directives provided by the state. Procedures related to transition should be made available to the state upon request. The state may provide ongoing training regarding transition activities. Staff from the LME/MCO are required to attend the state-sponsored training.

VII. Step by Step Procedures for Transition Planning: (see flowchart in Appendix) 1. Once an individual agrees to supported housing and transition, a housing slot must be obtained

within 10 days, triggering the change in TCLD to Transition Planning. 2. Once an LME/MCO is notified that a person has been conditionally approved for a TCLI housing slot,

the LME/MCO assigns a Transition Coordinator who will serve as the point person for the transition. Note: some LME/MCOs involve a Transition Coordinator during the In-Reach process. This person may partner with the In-Reach Specialist in requesting the housing slot.

3. If the individual does not have a current Comprehensive Clinical Assessment (CCA), the Transition Coordinator will partner with the individual/guardian and may partner with care coordination staff to obtain the CCA as quickly as possible, but no later than 30 calendar days from conditional housing slot approval.

4. The Transition Coordinator is responsible for convening a Transition Team that will be the hub of planning activities until the transition to supported housing occurs, but also remains as a resource during the follow-along and post-transition process.

5. Within 10 calendar days of the initial approval for a housing slot, the In-Reach Specialist facilitates a “soft transition” meeting between the Individual, the legal guardian (if applicable), natural supports, and Transition Coordinator (if they have not met before). The In-Reach Specialist will introduce the individual to the Transition Coordinator and share any information he/she has that will facilitate the warm hand off to the Transition Coordinator. A “warm hand off” is best practice and should be used as often as possible.

6. During the initial face-to face meeting, the Transition Coordinator becomes acquainted with the individual and begins outlining the transition process. If key documents were not obtained during the In-Reach process or Housing Slot Approval process, the Transition Coordinator will begin that will be needed and explain the guidelines for information to be shared with the LME/MCO and others.

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7. The Transition Coordinator in partnership with the assigned LME/MCO Care Coordinator, is responsible for ensuring that the comprehensive Person-Centered Planning (PCP) is inclusive of all clinical services, supports and goals, and that these are or will be in place and being provided prior to the move-in. The PCP must also include other services and supports to address goals related to: Other Health Needs, Housing, Employment, Community Participation, Financial Supports and Community Resources, and any other support/goal identified in the planning meetings. If a PCP already exists, it will be updated to include all necessary elements. This is essential during the transition phase because provision of services is delayed by providers when they refuse to accept hospital plans.

8. The PCP meeting may take place simultaneously with the initial Transition Planning meeting. If the meetings are not simultaneous, the PCP meeting should be scheduled at the beginning of the process, allowing the PCP to be submitted in a timely manner. This is important to preventing delays in the transition.

9. The Transition Coordinator will work with the individual to identify key people to be included in their initial Transition Planning / PCP meeting. The individual will also be educated on others who have core roles in transition (i.e. providers, DSS, housing specialist, care coordinator, medical provider, Housing Subsidy Administrator, SE, advocacy groups, etc.). Release of Information (ROI) forms will be signed to allow the Transition Coordinator to contact others and to confirm that the individual has consented to their involvement.

It is Important to obtain an ROI for communication with DSS, ACH and the Housing Subsidy Administrator, if possible, during initial meeting. If this is not appropriate to obtain these in the “soft transition” meeting, the ROIs will be done in the first formal Transition Planning meeting.

10. The Transition Coordinator will schedule the first Transition Planning / PCP meeting within 10 calendar days at a time and location that is convenient to the individual and family/guardian, ACH, hospital or other setting where the individual may be residing.

11. The Transition Coordinator will be responsible for notifying all individuals/agencies who are invited. 12. During the initial Transition Planning meeting, the individual will be given an opportunity to ask

questions or voice concerns that they may have. 13. The Transition Coordinator will outline steps in the transition process and begin to identify any

barriers that could impact a transition to supported housing within 90 days, per settlement requirements.

14. Information from the In-Reach/ Transition to Community Living Tool (Revision November 2017) that details individual functioning across multiple domains, will be shared to facilitate the conversation on how to plan and support the individual in community housing.

15. The In-Reach/ Transition to Community Living Tool (Revision November 2017) and PCP should be in alignment with their assessment of the individual’s needs and appropriate care

16. Tasks to be accomplished will be outlined with timeframes and assignments of team members who will take the lead in coordinating each aspect of care. This will include tasks for the individual as well. All tasks are to be documented in the recipient chart.

17. The Transition Coordinator will continue completing the In-Reach/Transition to Community Living Tool (Revision November 2017) that was utilized during the In-Reach process.

18. The Transition Coordinator will emphasize throughout the meeting that there are tasks and activities involved in the transition process, noting that each transition is individualized and the team will be flexible to meet the needs and preferences of each individual.

19. The Transition Coordinator will present key forms to establish the relationship with the Housing Subsidy Administrator, including the N.C. Supported Housing Program Tenant Application and

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Confidentiality Release form and a Referral for Transition Management Services (TMS). These forms will be completed during the meeting or within a week of the meeting.

20. Other forms that are completed during the housing search process may be introduced.21. TMS is a service contracted to the behavioral health providers by the LME/MCOs. All individuals

must be receiving TMS unless they have Assertive Community Treatment (ACT) provider. If theindividual has an ACT provider, the role of TMS will be performed by the ACT team.

22. The Transition Coordinator and team will review what was addressed in the meeting, prioritize tasksto be completed and schedule the next planning meeting. When possible, the team will develop aschedule for ongoing meetings that will include all relevant stakeholders, adding new teammembers as tasks are addressed (i.e. inclusion of DSS to address Special Assistance-In Home,medical provider for those with medical conditions that may require special attention, CommunityCare of North Carolina (CCNC) Care Manager to help individual become linked to a new medicalhome (if their physician has been an employee of the facility) and to discuss medication/pharmacyare issues, etc. If a team member is not able to attend in person, the Transition Coordinator willfacilitate their involvement telephonically.

23. During transition planning, the Transition Coordinator should be preparing the individual to co-facilitate their meetings and brainstorming with them prior to the meetings next steps that willoccur. They should also be asking the individual who they would like to have support them in theprocess.

24. Transition planning meetings will occur as scheduled to address all areas needed for successfultransition to supported housing within 90 days. The Transition Coordinator will address barriers withthe team and notify DHHS if there are areas that cannot be addressed at the local level.

25. The LME/MCO must ensure appropriate services are in place for individuals prior to transitioningthem into the community. The PCP, CCA and any additional assessment material are subject toreview by designated DHHS staff.

26. Once the PCP is complete, the transition process can continue to the lease signing phase.27. The Transition Coordinator will ensure that guidelines related to administration of the Quality of Life

(QoL) survey to the individual are met.a. The Pre-Transition QoL Survey assesses the individual’s experiences in the current living

arrangement, prior to transitioning to supported housing in the community. The surveyshould be conducted face-to-face, ideally in the early stages of transition planning after theindividual has said “yes” to supported housing. Pre-Transition surveys must be conducted nolater than the day prior to the individual’s transition date, i.e., before the effective date ofthe individual’s lease, to be considered timely. For example, if an individual says “yes” totransition on March 1 and transitions with a lease effective date of May 10, the surveyideally would be conducted in March or April and must be conducted by May 9 to beconsidered timely. Pre-Transition surveys should not be re-administered to individuals whohave left housing for a period of time and are being rehoused.

b. Follow-up surveys should also be conducted face-to-face with the individual. Calculated duedates for 11-Month and 24-Month follow-up surveys are 335 and 730 days after theindividual’s transition date. To be considered timely, follow-up surveys must be conductedbetween 30 days before and 30 days after their calculated due dates. For example, a surveywith a calculated due date of September 15 is considered timely if it is conducted betweenAugust 16 and October 15. If an individual leaves housing before a follow-up survey duedate and is subsequently rehoused, the follow-up survey due date is extended by thenumber of days the individual was not housed. Follow-up surveys should not be conductedwith individuals who are not in housing.

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c. The QoL Survey Refusal Form should be used to document if an individual has declined to participate at any of the three survey points- before transition and 11- and 24-month follow-ups. Valid documented refusals must meet the same timing requirements for completed Pre-Transition and Follow-Up surveys, and must clearly indicate the individual or the individual’s guardian declined participation. Refusal Forms should not be used to document that the individual could not be reached. If an individual declines participation early in the survey period, i.e., early in transition planning or early in the 60-day window for completion of follow-up surveys, the individual should be provided additional opportunities to complete the survey later in the survey period before a Refusal Form is submitted. No more than one Refusal Form should be submitted for a due survey.

d. Survey links: Pre-Transition Quality of Life Survey:

https://surveymax.dhhs.state.nc.us/TakeSurvey.aspx?SurveyID=72LLnp2K 11/24-Month Follow-up Quality of Life Survey:

https://surveymax.dhhs.state.nc.us/TakeSurvey.aspx?SurveyID=72LM352K Quality of Life Survey Refusal Form:

https://www.ncsurveymax.com/TakeSurvey.aspx?SurveyID=74KL77m3 28. The Transition Coordinator will provide justification to DHHS when transition extends beyond 90

days and next steps.29. The Transition Coordinator will ensure that the post-transition follow along guidelines are followed

with the intensity of interventions being individualized for each individual.30. Discuss the need to ensure the database information is maintained in a timely manner.

The following, outlines procedures in key areas. The Transition Team will prioritize tasks based on each individual.

A. Procedures -Vital Documents:

1. The Transition Coordinator is responsible for ensuring vital documents needed to facilitate thetransition process are available. These include but are not limited to:

a. birth certificate, Social Security Card or letter from Social Security Administration,Driver’s license or government issued or approved ID card, confirmation ofcustody/guardianship

i. Legal documents confirming that another person is the legal guardianii. Copies of power of attorney paperwork if there is another person responsible

for certain decisions for the individual (financial, medical, emergency, etc.)b. Criminal background check

i. Review to determine if there are items that could limit access to housing insome areas or may lead to denial by a property manager

ii. Evaluate need for a Request for Reasonable Accommodationsc. Credit history

i. Review to determine type of debts, when they were incurred, correlation withperson’s disability and attempts to remedy the issues in the past

ii. Evaluate need for Request for Reasonable Accommodationsd. Validation of payee status (self or other, including ACH)

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e. Verification of income and other financial resources2. The Transition Coordinator will determine if any of these were obtained during the In-Reach

process and secure copies of them for use in the transition process.3. If documents have not been obtained or are not available, guidelines outlined in the In-

Reach/Transition to Community Living Tool (Revision November, 2017) will be utilized.4. The Transition Coordinator will present information and needs to the Transition Team, where a

decision will be made on who will be responsible for obtaining needed documents. A time frameto receive them will be established by the team and monitored by the Transition Coordinator.

5. Should there be barriers that cannot be overcome by the team in obtaining needed documentsand information, the Transition Coordinator will inform DHHS and seek guidance/assistance viaemail to the Community Mailbox or telephone consultation, depending on urgency.

6. The Transition Coordinator could begin to discuss and/or explore expungement6 of criminalrecords, if applicable.

B. Procedures-Behavioral Health Linkage and Referral:

1. Following completion of a Comprehensive Clinical Assessment, the Care Coordinator/TransitionCoordinator will educate the individual/legal guardian on the services that are beingrecommended - including how these services will be part of the of resources to support theindividual in residing in supported housing.

2. The Transition Coordinator will update the Transition Team on recommendations.3. TCLI staff will meet with the individual/legal guardian and provide a list of available providers in

the LME/MCO provider network. The list will include the provider who completed the CCA, ifthis is within their continuum of services.

4. The Transition Coordinator will emphasize consumer choice in selecting provider and respectpreferences for location of service, access to transportation, etc.

5. The authorization process will also be explained, including the PCP process.7. The TCLI staff will assist the individual/guardian in contacting their selected provider and have

ROI forms completed - allowing the provider to become part of the Transition Team. This willinclude ensuring an appointment to start services with the provider is confirmed in a timelymanner, based on urgency of need.

8. The Transition Coordinator will modify provider roles and expectations based on whether theindividual will receive enhanced services or basic services.

9. The Transition Coordinator will educate the enhanced services provider about the TCLI processand inclusion of all services, not just enhanced services and goals into the PCP. The TransitionCoordinator will serve as the link to ensure the provider has access to all information needed.Goals related to developing skills needed to support community housing will be included alongwith the Transition Team member responsible.

6 General Statues related to Expunction of Records in North Carolina: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_15A/Article_5.pdf Application to initiate expunction in North Carolina: http://www.nccourts.org/forms/documents/1202.pdf

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10. The Transition Coordinator will emphasize the need for services to begin as soon as possible,including in the ACH or other facility, to ensure services are in place, relationships establishedand roles are clearly defined prior to the move-in.

11. The Transition Coordinator will facilitate discussion on elements for crisis plan, disaster plan andemergency plan during transition planning meetings. These will be included in the PCPdeveloped by the enhanced services provider or LME/MCO staff.

12. LME/MCO staff will provide information to the basic services provider on their role in thetransition process and partner to include information from their treatment plan in thecomprehensive PCP.

13. LME/MCO staff will be responsible for completing the PCP in the following circumstances:a. The CCA supports basic services, including medication management only (the Care

Coordinator will incorporate outpatient services strategies and goals into the PCP);b. The CCA indicates current services (medication management with primary care physician)

need to continue with other community supported services; orc. The individual refuses any behavioral health services (plan will address housing goals, life

goals, natural and community services and supports).14. The Transition Coordinator/Care Coordinator will ensure that the PCP is reviewed as part of

ongoing team meetings and updated as the individual’s needs change.15. The Transition Coordinator or designated person will submit the PCP, CCA and tool to the

Community Mailbox for review by the Monitoring Team/TCLI, as part of the final housing slotapproval.

C. Procedures-Other Health Needs:

1. The Transition Coordinator will review the In-Reach/Transition to Community Living Tool(Revision November 2017) to identify the medical home of the individual (if other than theACH), other specialty providers (chronic medical conditions, specialized treatments andtherapies) and pharmacy - if on medications.

2. The Transition Coordinator will meet with the individual/guardian to obtain ROI forms to consultwith CCNC (when applicable). The Transition Coordinator will also obtain records from CCNC andmedical providers, if records have not been received.

3. Information will be shared with the Transition Team. Goals and interventions needed to addresshealth and wellness issues will be identified and included in the PCP.

4. The Transition Coordinator will consult with the individual/guardian, ACH and existing medicalproviders to determine any existing appointments and future appointments during thetransition period and after move-in to ensure there is no lapse in services. As needed,transportation to appointment will be arranged or provided by TCLI staff.

5. When applicable, the Transition Coordinator will check the CCNC Informatics Database todetermine if there is a CCNC Care Manager and primary care provider assigned. If one isassigned, the Transition Coordinator with will contact the CCNC Care Manager and primary careprovider. Most individuals in an ACH have a physician employed by the ACH as their primary

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provider. Many do not have an identified Care Manager, unless there are complex health-related concerns.

6. When applicable, the Transition Coordinator will work with CCNC and the individual/guardian tofacilitate assignment to a primary care provider and medical home.

7. A ROI will be signed allowing information to be exchanged with the primary provider. TheTransition Coordinator will ensure any special needs identified in the transition planningmeetings are addressed.

8. The Transition Coordinator will facilitate completion of paperwork with the primary carephysician for access to ADA transportation if not in place.

9. The Transition Coordinator will work with the ACH physician or the individual’s primary carephysician for assessments and service orders on health services that need to be in place prior tomove-in, including home health and personal care, durable medical equipment, etc. Thephysician will also be consulted on prescriptions for medications to ensure there is no lapse inthe individual having medication during the transition. If physician does not do this, theTransition Coordinator will consult with CCNC and/or the new primary care provider.

10. The Transition Coordinator will work with the individual/guardian on selection of a pharmacy ifneeded. Consideration will be given to pharmacies near the apartment of the individual,preferably one that delivers medications.

11. If the individual has no special health care needs, the Transition Coordinator will ensure that theTransition Planning meetings address information on health and wellness (routine visual, dental,health exams). As appropriate, goals to address concerns in these areas will be identified andaddressed by the appropriate Transition Team member.

D. Procedures-Housing:

1. The Transition Coordinator shall work with the LME/MCO Housing Specialist when an individualis approved for a TCLI Housing Slot. Information obtained during In-Reach on preliminarypreferences for housing and special circumstances will be shared. The Housing Specialist will beasked to participate in transition planning meetings as needed. Additional expectations include,but are not limited to:

• Ensuring choice among multiple units in the community• Ensuring that the individual actually gets to visit and tour the potential apartment• Helping the individual to find housing in the community• Housing searches (TCLI recipients get priority for Target/Key units)• Collaborating with their Regional Housing Coordinators

2. The Transition Coordinator will identify the target date for move-in (within 90 days of initialtransition planning meeting) and outline target dates for completion of activities related tohousing. Specific dates will be detailed in the Transition Planning process for each individual.

3. When working with the Housing Specialist, Housing Specialists will share information onproperty managers who do not accept subsidies, those whose rent exceeds fair market value,

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complexes that may not meet standards based on inspections, the percentage of residents with disabilities etc., and have this available for planning meetings.

4. When necessary, reasonable accommodation should be requested.5. The Transition Coordinator will ensure each step identified below has a projected completion

date and an identified Transition Team member who is the point person. The TransitionCoordinator will monitor all tasks to ensure they are completed in a timely manner and shareinformation in Transition Planning meetings.

a. Submitting PCP, CCA, and tool to Community Mailbox for review before final approval ofhousing slot.

b. Identification of potential barriers to housing (criminal background, credit history, lackof available housing in preferred area, chronic medical conditions)

c. Identification of preferred geographic location (including in county, out of county) andother important factors (proximity to stores, laundromat, family and social network,transportation, etc.)

d. Individual selection of units to visit and prioritization of choicese. Arranging visits to units selected to include people individual wishes to have accompany

him/her on visitsf. Individual selection of preferred apartmentg. Coordinating a meeting with landlord to review and complete Tenant Application

including Request for Reasonable Accommodations, if applicableh. Securing funding for application fees (identified method of payment accepted and

amount)i. Identifying turn-around time on approval of Tenant Applicationj. Confirming deposit and due datek. Enter household, income and unit information in Community Living Integration &

Verification (CLIVe) this is the subsidy payment/reimbursement system run by NCHFAupload:

i. Request for Lease (RFL) for TCLV or Lease Notice – other Community Housingform for non-TCLV

ii. Tenant Household Composition and Income Summaryiii. TCLI Certification of Informed Housing Choiceiv. Waiver Requests, if applicable

l. For individuals utilizing Transitions to Community Living Voucher (TCLV) - coordinationof unit inspection; upload inspection reports and inspection invoice (if third partycontractor is used) in CLIVe

m. Assisting individual in submitting at least two weeks’ notice to ACH or other facility ofdischarge date

n. Scheduling lease signing dateo. Accompanying individual/guardian to landlord’s office to review and sign leasep. Enter security deposit, lease and HAP information in CLIVe and upload executed lease

and Housing Assistance Payment (HAP) contracts

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q. Establishing needed utilities (including funding for utility deposits and confirmingmethod of payment accepted- if targeted unit consultation with state for payment ofsecurity deposit)

r. Packing belongings and furnishings in preparation for the move-ins. Confirming move in day arrangements, including who will transport individual, transport

and/or deliver itemst. Assisting individual in setting up apartment

5. The Transition Coordinator will ensure that an inventory of the individual’s belongings and whatwill be needed to transition to their own apartments is done.

6. The Transition Coordinator is responsible for oversight and management of the one- timeTransition Year Stability Resources (TYSR) funds ($2,000). These funds are available to assist anindividual in safely and adequately meeting his/her transition related expenses during the firstyear. The funds must be utilized accordance with DHHS approved guidelines.

7. The Transition Coordinator will document the team member(s) responsible for accompanyingthe individual to purchase items and track the status of items identified in the inventory to makesure all needs are addressed.

8. Issues will be shared with the Transition Team with people identified to ensure everything iscompleted prior to transition.

9. The Transition Coordinator will follow procedures adopted by the respective LME/MCO forpurchasing items and processing of TYSR requests to DHHS for reimbursement.

The Housing Funds Guidelines Manual is available at: https://files.nc.gov/ncdhhs/documents/files/HousingFundsGuidelinesManual.pdf?7J4uxGZL27hFY.sPOFpcnoHR.FiV6BUT

10. The Transition Coordinator will submit a waiver request to DHHS for items outside of the DHHSTYSR fund guidelines, noting the justification for the purchase. Approval of the waiver requestmust be received before TYSR funds are used. DHHS will not reimburse the LME/MCO for itemspurchased prior to approval of a waiver request.

11. Purchasing items with the individual throughout the transition process is encouraged to ensurethat they are available on move-in day (except for fresh groceries).

E. Procedures-Financial Supports:

1. The Transition Coordinator will ensure financial supports needed for the individual areaddressed with the Transition Team and in the PCP.

2. The Transition Coordinator will address payee issues, including transfer of the ACH as payee toanother representative payee (including the individual in selection of representative payeeagency). The Transition Team will also assess whether the individual, who is his/her own payeebut has received supports to manage their finances from the facility, may need a temporarypayee to support their transition.

3. A Transition Team member will be identified to assist the individual in establishing a bankaccount if they do not have one.

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4. The Transition Coordinator will assign a team member to assist the individual in transfer ofbenefits with the Social Security Office to decrease any delays in benefits received.

5. The Transition Coordinator will follow all guidelines adopted by the Division of Aging and AdultServices (DAAS) to establish and address changes to Medicaid and Special Assistance-In homebenefits (initial application or change to Special Assistance/In-Home (SA-IH) for the TCLIpopulation. This will include completing the DHHS Economic Assistance Worksheet andproviding monthly payment tracking information for each individual). The TransitionCoordinator will assure that changes in the individual’s situation are reported to the DSS.

a. For individuals who choose to move outside of their current home Medicaid County,the Transition Coordinator will coordinate efforts between the two DSS agenciesand the receiving LME/MCO (transfer of Medicaid and other support funding).

6. The Transition Coordinator will follow guidelines to request CLA funding to cover lapse in receiptof SA-IH benefits while the transition process occurs using the DHHS Economic AssistanceWorksheet.

7. The Transition Coordinator will work with the individual/guardian to identify any outstandingdebts and develop strategies to address these.

8. If the individual’s credit history negatively impacts their ability to secure housing, strategies willbe developed with the individual and Transition Team to address. Request for ReasonableAccommodations will be completed as indicated.

9. A Transition Team member will be assigned to work with the individual on developing a budgetto follow once living in their own apartment. Goals related to money management will beincluded in PCP as appropriate.

10. The Transition Team will continue educating the individual on the options for SupportedEmployment, including the impact on benefits and advantages to employment.

F. Procedures-Community Resources:

1. The Transition Coordinator will review the interests, Important to and Important For, andcommunity resources information available from meetings with the individual/guardian and theIn-Reach/Transition to Community Living Tool (Revision November 2017). Current involvementand the desire to continue participating in activities will be emphasized.

2. The Transition Coordinator will meet with the individual/guardian to review this information andobtain information on other interests and resources available including, but not limited to, faithbased, social, recreational, volunteer, leisure, educational, advocacy oriented, support groups,employment and vocational interests that are important to be considered in transition planning.The availability of continuing existing transportation for current activities will be explored andoptions to consider if this is not possible (funding for bus passes, taxi services, gas forfamily/friends etc.).

3. A Transition Team member will work with the individual/guardian to assess communityresources available in all areas identified by the individual and facilitate linkage between theindividual and the community resources/supports.

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4. The Transition Coordinator and or transition team member will address potential volunteer andemployment opportunities during planning meetings and facilitate involvement of the In-ReachSpecialist and possibly Supported Employment provider to continue to explore interests andoptions.

5. The Transition Coordinator and or transition team member will include any mentoring, coachingand support strategies to assist individual in using public transportation and becomingintegrated into the community in transition planning and plan development.

6. A listing of other available transportation resources (family, friends) will be confirmed.7. Community Integration goals and supports will be included in the PCP.

G. Procedures-Final Transition Meeting:

1. The Transition Coordinator will convene a final meeting of the transition team at least twoweeks prior to the anticipated move-in. Once the PCP is complete, the lease signing process cancontinue. This date will be included on the schedule of meetings developed by the TransitionCoordinator in the early transition planning meetings.

2. The Transition Coordinator should ensure that all team members are invited to/reminded of themeeting with sufficient notice (suggested a minimum of seven business days) to participate(face-to-face or telephonically if unable to attend in person).

3. New team members who have been identified will be included in the final transition meeting.4. The Transition Coordinator will review with the transition team: the planning process, the

strategies, goals and supports identified and approved in the PCP and identify if there are anytasks not completed. The individual and/or guardian will be asked to share their perspective andideas on past and present concerns about moving into housing.

5. The Transition Coordinator will review the status of activities outlined in Housing Procedures toconfirm roles, responsibilities and any tasks to be completed in the final two weeks beforemove-in. The team will also identify others who wish to support the individual during the moveto supported housing. With the consent of the individual, the Transition Coordinator will addothers to the move-in team and detail their role.

6. The Transition Coordinator will ensure that plans to address crises (disaster, emergency,behavioral health crisis, medical crisis) are current with details, responsible people and currentphone numbers. The team will identify a member of the move-in team to ensure key telephonenumbers are posted in the apartment on the day of the move-in and easily viewed andaccessible to the individual.

7. The Transition Coordinator will confirm completion and submission of the Pre-Transition QoLsurvey.

8. The Transition Coordinator will plan for check-ins, face-to-face and telephonically, with theindividual in the interim between the final planning meeting and the move-in date. TheTransition Coordinator and others identified will offer support and encouragement but alsoaddress any last-minute transition issues, including access to staff and financial resources.

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H. Procedures-Follow Along (90 days post transition) and Post Follow Along:

1. Transition duties assigned during the Follow Along period (90 days post transition) will bedetailed by the Transition Coordinator in the transition planning meetings with the transitionteam. During transition planning, the frequency of Follow Along is routinely discussed to ensurethat a person’s housing, clinical activity needs, and issues related to health and safety areidentified and addressed on a timeline. Transition planning plays a vital role in assisting theindividual to maintain housing and critical services. A schedule of contacts will be developed andprovided to the individual, but may be more frequent based on individual needs.

2. The minimum frequency of visits as defined by the settlement includes:• First month: weekly in-person contact with individual• Second month: every other week in-person contact with individual• Third month: monthly contact in person

However, there is an expectation that the frequency of visits will be customized according to the individual’s level of need.

3. Follow Along tasks will be completed by the Transition Coordinator and/or Care Coordinator.These activities do not duplicate the role of TMS, enhanced services providers or otherresources and supports identified in the PCP.

4. The Transition Coordinator will convene the Transition Team to address any areas noted duringthe Follow Along period. If areas of concern are identified, the Transition Team may decide it’snecessary to make revisions to services and supports identified in the PCP. The revisions to thePCP could result in new services/supports or more intensive supports from existing providers.

5. The LME/MCO will define who conducts ongoing monitoring of the individual for as long ashe/she remains in the TCLI and include this information in their TCLI procedures. This willinclude conducting the QoL survey at 11- and 24-months’ post transition.

VIII. Other Administrative/Programmatic Guidelines

A. Documenting Transition Activities

Staff completing Transition activities for the LME/MCO must utilize the In-Reach/Transition to Community Living Tool (Revision November 2017) and any updated versions approved by DHHS. This document outlines key elements to support the In-Reach and transition process of the individual.

The LME/MCO shall document all transition activities in accordance with DHHS guidelines that include data entry into the web-based system in effect at a point in time (currently TCLD). Data entry should occur daily to ensure system data reflects real-time activities with individuals. An on-line training module will be developed for LME/MCOs use, allowing timely access to training for new employees and refresher training for existing staff. Once completed, it will be available on the state TCLI WEB PAGE7. The

7 http://www.ncdhhs.gov/mhddsas/providers/dojsettlement/index.htm

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current TCLD USER GUIDE8 is available for use. Data must be entered by the date indicated by the state to meet settlement and legislative reporting requirements. DHHS will keep LME/MCO staff apprised of deadlines should they change.

B. Transition Timeline and Overview

1. Person says “YES” to supported housing (day 1) 2. Request Housing Slot within 10 days 3. Initial Housing Slot approved 4. Within 10 calendar days of 3 (Initial Housing Slot Approved) warm hand-off between the In-

Reach Worker and Transition Coordinator. Within 10 calendar days of warm hand-off, there should be the first Transition Planning / PCP Meeting

5. Additional Transition Meeting as necessary 6. Within 30 calendar days of conditional housing slot approval, the PCP is submitted for final

housing slot review 7. Resolve any issues with PCP 8. Final Housing Slot approval 9. Services begin once PCP is approved by Utilization Review. 10. Begin financial worksheet. 11. Once property is located, arrange for an inspection. 12. Once inspection is passed AND final Housing Slot approval has been given, lease may be signed 13. Secure household items 14. Identify move-in date 15. No more than 100 days from 3 (Initial Housing Slot Approved) – move-in (services must be in

place, inspection must have been completed and passed, financials must be complete, lease must be executed)

*The goal is within 90 days from the first Transition Planning meeting, the individual will move.

8 https://www.socialserve.com/waitlist/Help.html?ch=NC&waitlist_id=11&back_ref=waitlist%3B11

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APPENDIX

TCLI Transition Coordination Workflow